Sandra S. Liu Alan J. Dubinsky ABSTRACT. The health care industry in Hong Kong has undergone major changes in organization as well as philosophy of operation since the 1970s. During this period, the Hong Kong government has also experienced a political transition from colonial status to a special ad- ministrative region of Mainland China. Because of the economic down- turn in East Asia, including Hong Kong, contraction of public spending has compelled the government to reconsider the alternatives for health care provision in Hong Kong. A number of multinational health care providers have entered this market and operate mainly in the private sector, including solely-owned clinics and alliances with existing hospi- tals. This paper provides an understanding of the evolution and devel- opment of the health care industry in Hong Kong and, on that basis, suggests elements of quality health care from the findings of a survey of patients. [Article copies available for a fee from The Haworth Document Deliv- ery Service: 1-800-342-9678. E-mail address: <getinfo@haworthpressinc.com> Website: <http://www.haworthpressinc.com>] INTRODUCTION Health care tends to be a major concern of many people. In fact, the significance of receiving adequate medical care will likely rise Sandra S. Liu is Associate Professor, Department of Marketing, School of Busi- ness, Hong Kong Baptist University, 6th floor, Business Studies Building, Renfrew Road, Kowloon Tong, Kowloon, Hong Kong (E-mail: sandra@net1.hkbu.edu.hk). At the time this article was written, Sandra S. Liu was a visiting scholar at the J. L. Kellogg Graduate School of Management, Northwestern University. Alan J. Dubinsky is Editor, Journal of Personal Selling and Sales Management, and Professor of Marketing, Minnesota State University System-Minneapolis, Col- lege of Management, 730 Hennepin Avenue, Minneapolis, MN 55403 (E-mail: du binsky@msus1.msus.edu). Health Marketing Quarterly, Vol. 17(4) 2000 E2000 by The Haworth Press, Inc. All rights reserved. 1 HEALTH MARKETING QUARTERLY 2 throughout the world, as the average age in most nations will increase. This age accretion will have serious implications for governments keen on providing effective and efficient medical care for their citi- zens (Peterson, 1999). Without good health, all the money in the world alone wont serve as a nostrum for the ailment or an anodyne for the sufferer. As philoso- pher Ralph Waldo Emerson opined: The first wealth is health. People, like a car, do get into disrepair and require medical treat- ment--be it preventative, acute, chronic, or emergency. And when medical problems surface, the aggrieved await a medical providers incantation for wellness. By and large, health care can be considered a credence good, which is an offering that the consumer will never be able to evalu- ate effectively owing to his or her lack of medical knowledge (Bloom and Reeve, 1990). For instance, perhaps a childs chickenpox were eradicated within two weeks; the formerly discomfited parents may feel satisfied, but perhaps had they gone to a different doctor, that physicians treatment may have reduced the healing process to one week. Their lack of medical knowledge, though, does not allow them to make this assessment. Or, for example, maybe a patients broken arm totally heals within six months. Had the patient seen another care provider, though, perhaps the arm would have been totally healed within three months. Again, the lack of medical knowledge precludes the patients making such an evaluation. Given the credence feature of health care, patients are likely to look for cues or signals (Bloom and Reeve, 1990) that are redolent of the quality of treatment they are likely to receive (or do receive) from a given provider (be it a clinic or hospital). The aesthetics of the office, the appearance of the staff, the rapport between the patient and the staff, and the speed of service, among other features, may be utilized as indicants of the adequacy of the medical care received. These surrogate indicators of service quality afford a patient relative cognitive ease with which to assess the efficaciousness of the service provider. Patients are consumers. They seek medical care (the offering) in order to receive a bundle of benefits (the utilities derived from receipt of the care: good health). And just like consumers, irrespective of the medical attention sought, they have certain perceptions of the offer- ing--be they favorable, unfavorable, or even neutral--vis--vis the ex- Sandra S. Liu and Alan J. Dubinsky 3 pected versus the actual quality level received. Much academic re- search (conceptual and empirical) has focused on consumer perceptions of health care in the United States (e.g., Furse et al., 1994; Fusilier and Simpson, 1995; Ostasiewske and Fugate, 1994; Raju, Lonial, and Gupta, 1995; Reidenbach and Sandffer-Smallwood, 1995). Considering perceptions of consumers in non-U.S. countries, though, is important for at least one major reason. Presupposing that perceptions of health care are equable irrespective of country appears dubious. Several recent investigations, for instance, found that such issues as food shopping behavior (Brunso and Grunert, 1998); the attributes, consequences, and values of perfumes (Valette-Flor- ence, 1998); and attitudes toward television advertisements (Witkowski and Kellner, 1998) differ across cultures. Moreover, Rossiter and Chan (1998) promulgate that an individuals ethncity (broadly defined to in- clude biological and physical characteristics, personality traits, and cultur- al values and norms) influences consumer behavior. Furthermore, Reis- inger and Turner (1998) briefly review the literature regarding differences between Eastern and Western values and discern that such differentia affect the nature of the interaction between Eastern tourists and their Western hosts. Thus, this extant work suggests that trying to apply U.S.- based findings in non-U.S. polities is indeed questionable. In light of this situation, a study was conducted regarding consum- ers perceptions of health care in Hong Kong. Specifically, the inves- tigation sought answers to the following two questions: (a) what dimen- sions of quality are perceived to be important by patients in hospital inpatient, outpatient, and emergency room segments, and (b) what is the relationship between these dimensions of quality and patients percep- tions of overall satisfaction of the services. The import of employing the Hong Kong context is discussed sub- sequently. Then, the method of the study is described. Next, study results are presented. Finally, managerial and future research implica- tions are provided. HONG KONG HEALTH CARE The global trends of consumerism and democratic movement have influenced the behavior of consumers in Hong Kong since the early 1980s (Hill 1988). Hong Kong consumers currently are not at the same stage as patients in the United States (Ostasiewski and Fugate, HEALTH MARKETING QUARTERLY 4 1994), where consumers of health care have an unprecedented oppor- tunity to express their views on various aspects of the health care system. Nonetheless, there has been increasing media exposure of medical mishaps occurring in Hong Kong hospitals. Under increasing pressure from the public, providing good quality health care in Hong Kong has been on the governments agenda (Hospital Authority, 1991). In fact, since the mid-1970s, a number of factors have adverse- ly affected the quality of health care service in Hong Kong (see Table 1). Among these factors are rising costs of health care provision, increasing community expectations of health care quality, and low morale among medical staff in subvented hospitals. These inimical phenomena led to the W. D. Scott report in 1985, which called for a comprehensive reform in the Hong Kong health care industry. The health care industry in Hong Kong encompasses both public and private systems. As there is only a nominal fee required for com- prehensive health care, the majority of Hong Kong people utilize the TABLE 1. Development of Health Care in Hong Kong Since 1970s Year Major Events in the Health Care Sector Before 1974 S Overcrowding in government hospital S Inefficient use of beds in sub-vented hospital 1974 S Publication of the White Paper The Further Development of Medical and Health Service in Hong Kong S Regional approach to hospital management was implemented; regional hospitals were established Mid 1970s S Rapid expansion of hospital services S Rapid increase in the costs of providing health care services S Rising community expectations of health care service quality S Low morale among staff in sub-vented hospitals S Overcrowding of and long queues in hospitals 1983 S Legislative Council called for a review of medical services 1984-1985 S The management consultancy W. D. Scott Pty Co. conducted an investigation into the health care services in Hong Kong 1986 S Public consultation on health care services 1988 S The establishment of the Provisional Hospital Authority 1990s S Establishment of the Hospital Authority S Staff functions were created to support medical staff; these staff functions provided continuous improvement in health care services S A Hospital Complaint System was created S A Patient Opinion Feedback System was created S The importance of high quality services was emphasized Extracted from the Hospital Authority Report, 1996. Sandra S. Liu and Alan J. Dubinsky 5 services from hospitals that are within the public system (Hospital Authority, 1991). Following the recommendation in the W. D. Scott report, the government established the Hospital Authority in 1995 to oversee and coordinate the activities in public hospitals. Its inception was predicated on the idea that the Hospital Authority could deploy resources in a more efficient manner, and hence help raise the quality of health care service. As of December 31, 1996, it managed 41 public hospitals and institutions (out of 60 hospitals in Hong Kong) and 25,500 hospital beds, accounting for 85.2 percent of all hospital beds in Hong Kong, or 4.05 public hospital beds per 1000 population (Hos- pital Authority, 1996). Health care services in Hong Kong are classified into primary (the patients first point of contact with the health care system), secondary (the more specialised and complex medical care which is usually provided in a hospital setting), and tertiary levels (care catered to a small proportion of patients requiring highly complex and specialised care), with acute and extended care (rehabilitation and long stay) components (http://www.ha.org.hk--Web site of Hospital Authority). The latter two levels are, in general, provided in a hospital setting, and over 90 percent of them are under the auspices of the Hospital Author- ity. In other words, while the private sector is providing 70 percent of the primary medical care, the Hospital Authority is almost exclusively responsible for extended and long-term care for the disabled, chroni- cally ill, and elderly (http://www.ha.org.hk--Web site of Hospital Au- thority). In addition to a new management structure, which aims at efficient and effective resource deployment, the Hospital Authority also implements customer-concern mechanisms. For instance, a staff- function section is created to provide continuous improvement for meeting rising expectations in health care service. Also, the Hospital Complaint System and the Patient Opinions Feedback System are set up to collect comments and suggestions from citizens. Despite such consumer-oriented efforts, recently a number of serious accidents (e.g., incorrect drug therapy, incorrect kidney dialysis) have occurred in some public hospitals, thus conducing to an image of worsening health care quality (The Hong Kong Standard, 1998). In line with the consumerism movement in Hong Kong, public hospitals should be adopting a market-driven approach to developing and implementing health care quality. Doing so requires health care administrators in Hong Kong to understand the perceptions of their HEALTH MARKETING QUARTERLY 6 external customers and, then, recommend areas for improvement. Ac- cordingly, the authors seek to identify aspects of health care quality that are vital to overall customer satisfaction in the public health care sector in Hong Kong. JUSTIFICATION FOR EXAMINING THE HONG KONG CONTEXT Hong Kong was selected as the population of interest for several reasons. First, Hong Kongs population size (6.6 million in 1998) and its geographical proximity to the demographic behemoth Mainland China betoken a substantial financial attraction for domestic and mul- tinational health care organizations interested in pursuing this market. Second, more and more service organizations are moving into the Hong Kong and Mainland Chinese markets, thus garnering an increas- ing proportion of their revenues from these foreign sources; similar pursuits may well prove propitious for multinational health care pro- viders. Third, health care organizations, like traditional manufacturing companies, are seeking ways to enhance efficiency while simulta- neously satisfying customers adequately. A merger with or an acquisi- tion of a host country health care provider may offer such a solution. Given the economic declension pervading Hong Kong (that will also probably soon envelop Mainland China), host country health care organizations may be especially amenable to such moves by multina- tional providers. Finally, attendant with the Asian financial debacle has been increasing caution regarding.how the Mainland Chinese gov- ernment allocates resources to industry (Lawrence, 1998). Prudent beneficence has become the watchword of those mandarins responsi- ble for dispensing government monies to business. Those health care organizations demonstrating skilled husbandry are more likely to re- ceive government resources than their less fiscally successful counter- parts. With the governments fiscal conservatism, host country health care organizations are likely to pursue multinational alliances to foster future business success. METHOD Sample A structured questionnaire was administered face-to-face to patients of inpatient, outpatient, and emergency room services in the general Sandra S. Liu and Alan J. Dubinsky 7 public hospital of each district across the territory, a total of eight districts according to the classification of the Hospital Authority (1997). Sizes of the hospitals ranged from 300 to 1,000 beds. A total of 320 subjects were interviewed during the period from February to April in 1998. The profile of subjects is shown in Table 2. There are 126 subjects in the inpatient, 91 in the outpatient, and 97 in the emergency room sub-sample. The education level, employment status, and income level are indicative of the general population using health care services of public hospitals (http://www.ha.org.hk--Web site of Hospital Author- ity). Among the respondents, 57.6 percent are male and 42.4 percent are female, but they are mostly under the age of 49, which constitutes 78 percent of the total sample. Measurement A number of studies (Kleinsorge and Koenig 1991; Soliman 1992) have adopted SERVQUAL (Parasuraman, Zeithaml, and Berry, 1985; 1988) to assess patient perceptions of service quality of health care. Reidenbach and Sandifer-Smallwood (1990) adopted SERVQUAL and expanded it into forty-one service evaluative criteria based on ten dimensions (see Table 3). The ten included Tangibles, Accessibility, Understanding, Courtesy, Reliability, Security, Credibility, Respon- siveness, Communication, and Competence. The present study slight- ly modified these items to reflect the situation in Hong Kong. Independent Variables. Five items of Reidenbach and Sandifer- Smallwoods (1990) questionnaire, as indicated in Table 3, were not suitable for the Hong Kong health care environment. Thus, a thirty-six item scale taken from their work was used to measure patients per- ceived quality (from 1 = very good to 5 = very bad) of various aspects of hospital health care services. Separate factor analyses (us- ing varimax rotation) were employed to determine the underlying dimensions of these 36 items for each sub-sample (inpatient, outpa- tient, and emergency patients). The screen test criterion was utilized to ascertain the number of extracted factors for each sub-sample (Cattell, 1996). An item was assigned to a factor if its factor loading was at least 0.5, as suggested by Hair et al. (1995). If the item cross-loaded on at least two factors, it was eliminated from subsequent analyses. Re- maining items were summed and divided by the number of items within the factor to arrive at a mean score for each service dimension HEALTH MARKETING QUARTERLY 8 TABLE 2. Profile of Respondents Characteristics No. of % Respondents Sub-sample Inpatient 126 40.1% Outpatient 91 29.0% Emergency Room 97 30.9% Sex Male 181 57.6% Female 133 42.4% Age 15-19 5 1.6% 20-29 72 22.9% 30-39 93 29.6% 40-49 75 23.9% 50-59 48 15.3% 60 or above 21 6.7% Household $4,999 or below 199 63.4% income $5,000-$9,999 36 11.5% $10,000-$14,999 66 21% $15,000-$24,999 9 2.9% $25,000-$29,999 1 0.3% $30,000-$34,999 1 0.3% $35,000-$39,999 1 0.3% $40,000-$49,999 1 0.3% Career Worker 34 10.8% Clerk 59 18.8% Professional 20 6.4% Student 38 12.1% Housewife 50 15.9% Unemployed/Retired 110 35.0% Others 3 1.0% Education No formal education 66 21% Primary education 88 28% Secondary education 113 36% Matriculation 13 4.1% Post secondary/University 26 8.3% Above university 8 2.5% for each sub-sample. Coefficient alpha was computed to discern the reliability of each dimension. The 36 service dimension items were subsumed by four factors in the inpatient subsample, constituting 54 percent of the variance (see Appendix 1A). The four are care and concern (coefficient alpha = 0.95), responsiveness (alpha = 0.80), appearance (alpha = 0.73), and comfort (alpha = 0.62). The factor analysis of the outpatient sub-sample yielded five fac- tors, comprising 55 percent of the variance (see Appendix 1B). The underlying dimensions were as follows: medical staff (alpha = 0.94), time and convenience (alpha = 0.79), environment (alpha = Sandra S. Liu and Alan J. Dubinsky 9 TABLE 3. Service Evaluative Criteria a Tangibles Cleanliness of the hospital Pleasantness and appeal of the hospital room Professional appearance of hospital staff Professional appearance of other hospital employees Temperature of the food Taste of the food Timing of the meals Physical appearance of your room Accessibility Availability of visitor parking Availability of information about your condition Ease of getting hold of hospital personnel on the phone Availability of meals for the family Availability of sleeping accommodations for your family b Understanding Concern for family and visitors Concern for your particular needs Amount of time spent by staff getting to know and understand your needs Courtesy Politeness of physicians Politeness of the nurses Politeness of other hospital staff Reliability Performance of services when they were supposed to be performed Performance of services the way you were told they would be performed Security Sense of security from physical harm that you felt in the hospital Sense of wellbeing you felt in the hospital Credibility Ability of the hospital to deliver what was promised in their advertising b Ability of the hospital to treat you the way you expected to be treated Responsiveness Responsiveness of the nurses to your needs Responsiveness of the physicians to your needs Waiting time for tests Speed and ease of admissions Speed and ease of discharge Waiting time for refund (if due) b Waiting time for education Time between admission and getting into your room Communication Adequacy of instructions given at time of release on how to care for yourself Adequacy of explanation about your condition and treatment by hospital staff Instructions about billing procedures Competence Skill of the nurses attending you Skill of the physicians attending you Skill of those who performed the tests b Accuracy of the billing procedures Competence of the staff in filing insurance claims b HEALTH MARKETING QUARTERLY 10 TABLE 3 (continued) Dependent Variables How would you rate the overall level of service you received as a patient in the hospital? Very Good _____ Good _____ Neutral _____ Bad _____ Very Bad _____ How satisfied were you with the treatment you received in the hospital? Very Satisfied ____ Satisfied ____ Neutral ____ Dissatisfied ____ Very Dissatisfied ____ How willing would you be to recommend this hospital to a friend of yours? Very Willing ____ Somewhat Willing ____ Neither _____ Somewhat Unwilling ____ Very Unwilling _____ As a result of your visit, how willing would you be to complain to your family and friends about the care received? Very Willing _____ Somewhat Willing _____ Neither _____ Somewhat Unwilling _____ Very Unwilling _____ a Operationalized as a 5-point scale in the following form: Very Good ______ Good ______ Neutral ______ Bad ______ Very Bad ______ b Item removed from the questionnaire designed because it is not germane to public hospitals in Hong Kong. 0.72), ancillary staff (alpha = 0.60), and billing procedure (alpha = 0.73). Four factors were generated in the emergency sub-sample, explain- ing 71 percent of the variance (see Appendix 1C). The four were comprised of emotional comfort (alpha = 0.91), speed and accura- cy (alpha = 0.93), competency (alpha = 0.86), and auxiliary services (alpha = 0.34). Because of the low reliability of the auxil- iary services dimension, it was omitted from subsequent analyses of the emergency sub-sample. Dependent Variable. The dependent variable--satisfaction with hos- pital health care services--was taken from the same study as the inde- pendent variables (Reidenbach and Sandifer-Smallwood, 1990). Re- spondents were asked to rate the following items: (a) perception of the services they received (1 = very good and 5 = very bad), (b) the level of satisfaction with their treatment (1 = very satisfied and 5 = very dissatisfied), (c) willingness to recommend the hospital to their friends (1 = very willing and 5 = very unwilling), and (d) willing- ness to complain to their family and friends about the health care that they had received (1 = very willing and 5 = very unwilling). Separate factor analyses (using varimax rotation) were employed to determine the underlying dimensions of these four items for each sub-sample. Factor analyses revealed that for all sub-samples, the four items comprised one overridden dimension and that one item (regard- ing the respondents likelihood of complaining to relatives about the hospital service) was below the 0.50 factor loading cutoff point. Thus, the final satisfaction measure consisted of three items (after omitting Sandra S. Liu and Alan J. Dubinsky 11 the complaints item); for each sub-sample, this measure was summed and divided by three to yield an average score. Coefficient alpha for this measure for each sub-sample was as follows: inpatient, 0.88; outpatient, 0.80; and emergency, 0.71. Although previous stud- ies examined each of the four satisfaction items separately in their work, we chose to utilize an aggregate measure of service satisfaction because one-item measures have unknown reliability. Data Analysis Each sub-samples data were analyzed separately using multiple regression. All underlying service dimensions (factors) were forced into the regression model to ascertain the percent of variance ex- plained in patient satisfaction from the entire matrix of independent variables as well as the strength and direction of each dimensions relationship with satisfaction. Prior to conducting multiple regression, variance inflation factors (VIFs) were computed to assess multicollin- earity among the independent variables. All VIFs were less than 3.0, which are within an acceptable range (Montgomery and Peck, 1982). FINDINGS Shown in Table 4 are the findings of the study for each sub-sample. Depicted for each sub-sample are the F value for the overall model and its concomitant significance level and adjusted R square, as well as the beta coefficients and their respective significance levels. Inpatient Results. The overall regression model for public hospital inpatient respondents is significant (F = 60.56, p < .000) and explains 66 percent of the variance in patient satisfaction. Also, all four hospital service dimensions are significantly related (p < .01) to satisfaction. Care and concern, appearance, and comfort are positively related to inpatient satisfaction with hospital services. Interestingly, however, responsiveness is inversely associated with inpatient sat- isfaction toward the hospitals services. These results imply that when a hospital evidences increased levels of concern for the patient, pro- vides aesthetically appealing surroundings, and bestows a feeling of comfort on its patients, inpatient satisfaction augments. When the hospital staff is expeditious in its efforts, though, such responsiveness can conduce to a decrement in inpatient satisfaction. Outpatient Results. Twenty-four percent of public hospital outpa- HEALTH MARKETING QUARTERLY 12 TABLE 4. Service Dimensions Affecting Perceptions of Service Quality Subsample R 2 /Sig. F Dimension Beta Sig. Inpatient .656/.000 Care and Concern .735 .000 Responsiveness .224 .001 Appearance .173 .006 Comfort .212 .000 Outpatient .238/.000 Hospital Staff .263 .025 Time and Convenience .321 .001 Other Hospital Staff .179 .083 Environment .112 .242 Emergency Room .674/.000 Emotion and Comfort .883 .000 Speed and Accuracy .068 .647 Competency .100 .554 tient satisfaction with the hospital is explained by the five service dimensions (F = 6.42, p < .000) (see Table 4). Medical staff and time and convenience are significantly and positively related (p < .05) to outpatient satisfaction; moreover, there is tentative evidence that ancillary staff is positively associated (p < .10) with outpatient satisfaction. Two of the five dimensions, though, are unrelated (p > .05) to outpatient satisfaction with hospital services; the two are en- vironment and billing procedure. These findings suggest that out- patient satisfaction can be enhanced to the extent that medical staff (namely, physicians and nurses) evince competence, that services are administered in a timely and commodious fashion, and that ancillary staff (chiefly, employees other than physicians or nurses) manifest an appropriate appearance and bedside manner. Emergency Room Patient Results. The overall model for public hospital emergency room patient satisfaction explains 67 percent of the variance (F = 12.70, p < .000), yet only one of the three factors is significantly associated with satisfaction. More specifically, emo- tional comfort is positively related (p < 0.000) to emergency room patient satisfaction. Speed and accuracy and competence, how- ever, are unrelated (p > .05) to satisfaction with hospital service. DISCUSSION The national health system in Hong Kong allows all citizens to enjoy basically free care, if they so choose. The demographic profile of the subjects in our study reflects a possible reality that, while Sandra S. Liu and Alan J. Dubinsky 13 privately-owned for-profit clinics/hospitals provide good care for the wealthier patients (based on market-driven principles), they seemingly shunt the poor to more crowded public hospitals. For instance, 63.4 percent of the sample has a household income of below $5000, and 85 percent only has achieved a secondary school level. This cohort of citizens seemingly is unable to afford relatively expensive private health care and therefore must utilize services from public hospitals. Public hospital patients are well aware of the protracted waiting time for treatment in the outpatient section, which is a common phenome- non for this type of health-care system (Weber, 1998). However, when admitted to the inpatient section, patients are being attended to in a fashion that is similar to an assembly line--and even in some cases are cared for mainly by nurses and/or ancillary staff. In addition, it should be noted that different types of patients per- ceive service dimensions for quality health care differently. For instance, those with inpatient needs mainly focus on the care and concern of the staff, those in the outpatient segment emphasize time and convenience, and emergency room patients stress emotion and comfort. Moreover, factors contributing to service satisfaction of the three segments of patients are also variegated. Patients in the inpatient segment are satisfied when hospital staff shows care and concern, the appearance of the hospital is pleas- ant, and they are made to feel comfortable. However, as mentioned previously, those who utilize services from these hospitals have had negative experiences in terms of their medical care at the hospital. The huge number of patients per room in a ward (8 to 10 is commonplace [http://www.ha.org.hk--Web site of Hospital Authority]) and the large patient to medical staff ratio make the medical care similar to an assembly line operation. It is, therefore, reasonable to observe a nega- tive relationship between the dimension of responsiveness and pa- tient satisfaction in this category. Patients may perceive responsive- ness ( la expedience) as the possibility of not being attended with care. (In contrast, those in the outpatient segment consider time and convenience to be an important factor contributing to their satisfac- tion. This is consistent with Hui and his colleagues [1998] findings that the satisfaction of customers in the inservice stage is not so much affected adversely by waiting than the satisfaction of customers in the pre-service stage.) Furthermore, responsiveness in service may be seen by the inpatient subjects as a reflection of disengagement of the HEALTH MARKETING QUARTERLY 14 hospital staff. Thus, when coupled with the effect of care and con- cern, our findings suggest that hospital staff should spend sufficient time communicating with the patients in the inpatient segment and understanding their needs, even when such activity may slow down the administrative process. Providing patients with care and comfort by the hospital staff is a core concern regardless of which segment of hospital care the patient utilizes. The elements entail such characteristics as professionalism of the staff and business operations of the hospital. This finding is consis- tent with that of Reidenbach and Sandifer-Smallwood (1990) and corre- sponds to the original conceptual service dimensions of reliability, com- petence, and tangibles (Parasuraman, Zeithaml, and Berry, 1985). In fact, the manner of hospital staff (in providing emotional care) is the sole important contributor to the satisfaction of the patients in the emergency room segment. In Hong Kong, there frequently are long waiting lists for patients to be examined in the hospital for their sus- pected medical problem; so, many utilize emergency room services for immediate medical check-ups (The Hong Kong Standard, 1997). Patients visiting the emergency room are mainly looking for initial diagnosis of the nature of their illness and attaining some preliminary treatment, in addition to other regular emergency functions (e.g., trau- ma and sudden attacks of some diseases). Consequently, speed of administration and competence of staff are not so critical. Rather, the manner of the staff and comfort provided reflect to patients the im- pression that the hospital is well managed and resourceful and that the staff is certainly willing to help. Otherwise, the patient may not have the confidence that the hospital will have the necessary employee resources to provide satisfactory services. POLICY IMPLICATIONS Public hospitals have been considered as the choice of health-care for citizens in the lower income bracket in Hong Kong. These hospi- tals have suffered a negative image over the years. The status of being the teaching hospitals for major medical schools in Hong Kong uni- versities has, however, provided an opportunity for these public hospi- tals to promote themselves as technically more innovative and ad- vanced. The quality-circle concept suggested by Ostasiewske and Fugate (1994) allows hospitals to enhance communication between Sandra S. Liu and Alan J. Dubinsky 15 staff and patients and, in turn, helps hospitals anticipate as well as solve problems. Owing to limited channels through which public hospitals gather patients opinions, such as leaflets informing people what sort of service hospital provided. It, however, is not enough and this is just a one-way communication. Thus, considering use of the Patient Circle seems beneficial. This tool uses the conventional quality circle in a small group which numbers between 4 and 15, subordinated by em- ployees who voluntarily meet on a regular basis to discuss common work-related problems, identify causes, develop solutions, and make remedial proposals to management. Accepted proposals are expected to contribute to production efficiency and quality control as well as have enthusiastic employee support. Techniques for enhancing patients service include marketing research to determine the wants and demands of patients and their satisfaction levels. Recruitment, retention, and promotion programs focusing on per- sonnel having a strong service orientation are recommended. Each de- partment should define its role or mission in patient service terms. Health- care providers, especially the ancillary staff, should be trained to understand patient perceptions and, in turn, respond to them accordingly. As health-care requires specialized knowledge, in-house customer de- signed training and educational programs are recommended to focus on patient service, empowerment of employees, and recognition and reward for employees with outstanding performance in customer services. As there is a contraction of public spending recently and continued reform of health care system in Hong Kong (http://www.ha.org.hk-- Web site of Hospital Authority), an opportunity is therefore created upon which multinational health care providers can capitalize. The current problem of long waiting lists and the lack of personal attention given to patients utilizing inpatient services could be rectified by customer-oriented services provided by these private companies. Of course, how to strike the balance of cost-effectiveness and quality of services would be a major challenge to these new comers. The find- ings of this study will, however, provide important indicators for the companies to plan for their ventures in Hong Kong. FUTURE RESEARCH This study seeks to understand patients evaluation of service quali- ty of health care during their encounter with hospitals. This is in line HEALTH MARKETING QUARTERLY 16 with the recent view in services marketing that promulgates the ser- vice encounter is the moment of truth, and the evaluation of service quality at these specific time intervals is important. However, Hui and his colleagues (1998) study suggests that the stage of the service process is also important. 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Factor Structure for Inpatient Sub-Sample FACTOR % Variance Reliability Item Factor Loading Explained 1: Care and Concern 35.826 0.9499 concern for your particular needs 0.812 bedside manner of physicians 0.801 amount of time spent by staff getting to know and understand your needs 0.798 performance of services when they were supposed to be performed 0.765 responsiveness of the nurses to your needs 0.734 skill of the physicians attending you 0.730 responsiveness of the physicians to your needs 0.728 sense of wellbeing you felt in the hospital 0.715 bedside manner of the nurses 0.706 skill of the nurses attending you 0.698 ability of the hospital to treat you the way expected to be treated 0.695 bedside manner of other hospital staff 0.591 adequacy of instructions given at time of release on how to care for yourself 0.542 2: Responsiveness 6.744 0.8004 ease of getting hold of hospital personnel on the phone 0.685 accuracy of the billing procedure 0.666 speed and ease of discharge 0.629 speed and ease of admissions 0.625 waiting time for medication 0.510 3: Appearance 6.132 0.7339 pleasantness and appeal 0.788 cleanliness of the hospital 0.747 physical appearance of the room 0.655 professional appearance of hospital staff 0.548 4: Comfort 5.347 0.6249 timing of the meals 0.768 temperature of the food 0.624 Sandra S. Liu and Alan J. Dubinsky 19 APPENDIX 1B. Factor Structure for Outpatient Sub-Sample FACTOR % Variance Reliability Item Factor Loading Explained 1: Medical Staff 25.952 0.9371 bedside manner of physicians 0.891 responsiveness of the physicians to your needs 0.824 responsiveness of the nurses to your needs 0.789 skill of the physicians attending you 0.787 bedside manner of the nurses 0.775 concern for your particular needs 0.774 performance of services the way you were told they would be performed 0.702 amount of time spent by staff getting to know and understand your needs 0.680 sense of wellbeing you felt in the hospital 0.671 adequacy of explanation about your condition and treatment by hospital staff 0.591 performance of services when they were supposed to be performed 0.513 ability of the hospital to treat you the way expected to be treated 0.512 2: Time and Convenience 9.930 0.7914 waiting time for medication 0.823 time between admission and getting in your room 0.790 waiting time for tests 0.744 speed and ease of admissions 0.610 availability of meals for the family 0.557 ease of getting hold of hospital personnel on the phone 0.504 3: Environment 7.987 0.7155 physical appearance of the room 0.845 pleasantness and appeal 0.693 availability of visitor parking 0.617 sense of security from physical harm that you felt in the hospital 0.586 4: Ancillary Staff 5.758 0.5991 physical appearance of other hospital employees 0.762 bedside manner of other hospital staff 0.753 skills of the nurses attending you a 0.564 5: Billing Procedure 5.145 0.7320 instructions about billing procedures 0.857 accuracy of the billing procedure 0.644 a The item was eliminated in the subsequent analysis because it is cross-loaded. HEALTH MARKETING QUARTERLY 20 APPENDIX 1C. Factor Structure for Emergency Room Sub-Sample FACTOR % Variance Reliability Item Factor Loading Explained 1: Emotional Comfort 33.241 0.9076 bedside manner of physicians 0.900 ability of the hospital to treat you the way expected to be treated 0.895 sense of security from physical harm that you felt in the hospital 0.858 sense of wellbeing you felt in the hospital 0.799 bedside manner of other hospital staff 0.757 performance of services when they were supposed to be performed 0.742 bedside manner of the nurses 0.738 amount of time spent by staff getting to know and understand your needs 0.729 performance of services the way you were told they would be performed 0.649 adequacy of explanation about your condition and treatment by hospital staff 0.550 physical appearance of the room a 0.511 2: Speed and Accuracy 19.124 0.9330 speed and ease of admissions 0.933 speed and ease of discharge 0.923 instructions about billing procedures 0.914 accuracy of the billing procedure 0.905 taste of the food 0.696 3: Competency 11.267 0.8561 skill of the nurses attending you 0.870 skill of the physicians attending you 0.870 responsiveness of the nurses to your needs 0.793 professional appearance of hospital staff 0.727 responsiveness of the physicians to your needs 0.685 4: Auxiliary Services 6.960 0.3406 timing of the meals 0.896 availability of visitor parking 0.733 adequacy of instructions given at time of release on how to care for yourself 0.621 temperature of the food 0.589 a The item was eliminated in the subsequent analysis because it is cross-loaded.